Department of Cardiology and Cardiac Surgery, University of Debrecen, Debrecen, Hungary.
Department of Radiology (Medical Imaging Clinic), University of Debrecen, Debrecen, Hungary.
ESC Heart Fail. 2021 Oct;8(5):3975-3983. doi: 10.1002/ehf2.13496. Epub 2021 Jun 28.
The current guidelines on pulmonary hypertension (PH) recommend the use of invasive examination for differentiating between left-sided heart disease-related (post-capillary) and pre-capillary PH. However, atrial sizes are considered markers of ventricular filling pressures. Therefore, we aimed to test the clinical applicability of atrial volumes measured by transthoracic three-dimensional echocardiography (3DE) in differentiating between pre-capillary and post-capillary PH.
Seventy-five consecutive patients with PH were prospectively examined with transthoracic 3DE. After less than 24 h, the patients underwent right heart catheterization and 3DE and were classified as pre-capillary or post-capillary PH according to the recommendations of the ESC guidelines. The atrial volumes were measured offline with dedicated commercial software. Thirty-eight patients (13 men, age 65 ± 18 year) had pre-capillary PH, and 37 (23 men, age 62 ± year) had post-capillary PH. The mean pulmonary artery pressures were similar in patients with pre-capillary and post-capillary PH (38 [IQR 26, 54] mmHg vs. 41 [IQR 33, 48] mmHg, respectively, P = 0.49). The left atrial indexed maximum (LAVi max) and minimum (LAVi min) volumes were significantly larger in the post-capillary PH patient group than in the pre-capillary PH patient group (LAVi max: 64 ± 32 mL/m vs. 41 ± 25 mL/m , P = 0.001; LAVi min: 50 ± 22 mL/m vs. 26 ± 24 mL/m , P < 0.0001). The indexed right atrial minimum volume (RAVi min) was also higher in patients with post-capillary PH (51 ± 27 mL/m vs. 38 ± 26 mL/m ; P = 0.02). Both the left atrial (LA) and right atrial (RA) volumes, especially the LA minimum volume, correlated with the pulmonary artery wedge pressure (PAWP) (r = 0.62 (P < 0.0001) for LAV min vs. r = 0.49 (P < 0.0001) for LAV max; r = 0.32 (P = 0.005) for RAV min vs. r = 0.24 (P = 0.04) for RAV max). Multivariate logistic regression analysis showed that LAVi min was an independent predictor of post-capillary PH. In the receiver operating characteristic (ROC) curves of parameters predicting the post-capillary PH, the areas under the curve (AUC) for LAVi min, LAVi max, and RAVi min were 0.86 (95% CI, 0.76-0.95), 0.78 (95% CI, 0.67-0.89), and 0.66 (0.53-0.78), respectively. Concerning the performance of the atrial volume ratio for differentiating post-capillary PH, the AUC of the atrial volume ratio was significantly lower [AUC: 0.66 (95% CI, 0.53-0.78)]. The ROC analysis indicated a possible cutoff value of 27.7 mL/m for LAVi min to predict post-capillary PH (AUC = 0.86; sensitivity = 86%, specificity = 76%).
The BSA-indexed left atrial minimum volume measured by transthoracic 3DE is a useful parameter for differentiating pre-capillary from post-capillary pulmonary hypertension.
目前的肺动脉高压（PH）指南建议使用有创检查来区分左心疾病相关（后向毛细血管）和前向毛细血管 PH。然而，心房大小被认为是心室充盈压的标志物。因此，我们旨在测试经胸三维超声心动图（3DE）测量的心房容积在区分前向毛细血管和后向毛细血管 PH 中的临床适用性。
75 例连续 PH 患者前瞻性接受经胸 3DE 检查。在不到 24 小时后，患者接受右心导管检查和 3DE，并根据 ESC 指南的建议分类为前向毛细血管或后向毛细血管 PH。心房容积使用专用商业软件离线测量。38 例（13 例男性，年龄 65±18 岁）患者为前向毛细血管 PH，37 例（23 例男性，年龄 62±岁）患者为后向毛细血管 PH。前向毛细血管 PH 和后向毛细血管 PH 患者的平均肺动脉压相似（分别为 38[IQR 26，54]mmHg 和 41[IQR 33，48]mmHg，P=0.49）。后向毛细血管 PH 患者组的左心房指数最大（LAVi max）和最小（LAVi min）容积明显大于前向毛细血管 PH 患者组（LAVi max：64±32 mL/m 与 41±25 mL/m ，P=0.001；LAVi min：50±22 mL/m 与 26±24 mL/m ，P<0.0001）。后向毛细血管 PH 患者的右心房指数最小容积（RAVi min）也较高（51±27 mL/m 与 38±26 mL/m ，P=0.02）。左心房（LA）和右心房（RA）容积，特别是左心房最小容积，与肺动脉楔压（PAWP）相关（LAV min 的 r 值为 0.62（P<0.0001），LAV max 的 r 值为 0.49（P<0.0001）；RAV min 的 r 值为 0.32（P=0.005），RAV max 的 r 值为 0.24（P=0.04））。多变量逻辑回归分析显示，LAVi min 是后向毛细血管 PH 的独立预测因子。在预测后向毛细血管 PH 的参数的受试者工作特征（ROC）曲线中，LAVi min、LAVi max 和 RAVi min 的曲线下面积（AUC）分别为 0.86（95%CI，0.76-0.95）、0.78（95%CI，0.67-0.89）和 0.66（0.53-0.78）。关于心房容积比区分后向毛细血管 PH 的性能，心房容积比的 AUC 显著较低[AUC：0.66（95%CI，0.53-0.78)]。ROC 分析表明，LAVi min 的可能截断值为 27.7 mL/m，可预测后向毛细血管 PH（AUC=0.86；敏感性=86%，特异性=76%）。
经胸 3DE 测量的 BSA 指数左心房最小容积是区分前向毛细血管和后向毛细血管肺动脉高压的有用参数。
